<div class="appointmentcontainer">

    <form id="profilesList">
    
    <div class="searchcontainer">
	    <div>
		    <div style="width: 80%;float: left;padding-top: 20px">
			    <label class="searchformlabel" ><strong>Patient Name:</strong></label> 
		    	<input type="text" id="patientName" value="" />
		    </div>
		    <div style="width:20%;float:right">
		    	<img class="s-img" id="patientImg" src="/assets/images/no_person.png">
		    </div>
	    </div>
	    <div>
		    <div style="width: 50%;float: left;padding-top: 20px">
			    <label class="searchformlabel" ><strong>Patient Phone#:</strong></label> 
		    	<input type="text" id="patientPhone" value="" />
		    </div>
		    <div style="width:50%;float:right;padding-top: 20px;">
		        <label class="searchformlabel" ><strong>Patient Email:</strong></label> 
		    	<input type="text" id="patientEmail" value="" />
		    
		    </div>
	    </div>
	    
	    <div>
		    <div style="width: 80%;float: left;padding-top: 20px">
			    <label class="searchformlabel" ><strong>Refer to(Dr.):</strong></label> 
		    	<select class="" id="referredDoctorName" >
				</select>
		    	
		    </div>
		    <div style="width:20%;float:right">
		    	<img class="s-img" id="doctorImg" src="/assets/images/no_person.png">
		    </div>
	    </div>
	    <div>
		    <div class="referHospital dnone" style="width: 80%;float: left;padding-top: 20px;" >
			    <label class="searchformlabel" ><strong>Select Hospital:</strong></label>
				<select class="" id="selectReferredHospital" >
				</select>
			     
		    </div>
	    </div>
	    
	    <div>
		    <div class = "dnone" style="width: 80%;float: left;padding-top: 20px;">
			    <label class="searchformlabel" ><strong>Select Problem:</strong></label> 
				<select class="" id="selectProblem" multiple="multiple">
				</select>
		    </div>
	    </div>
	    <div>
		    <div class="dnone" style="width: 80%;float: left;padding-top: 20px;">
			    <label class="searchformlabel" ><strong>Additional Comments:</strong></label> 
		    	<textarea id="otherdetails" rows="5" cols="60"></textarea>
		    </div>
	    </div>
	    
	    <div>
	    		<input type="button" id="searchRefer" value="Refer">
	
	    </div>
   </div>
   
    </form>    
</div>